ACG updates guidance for celiac disease diagnosis, management in children, adults
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The ACG has published updated guidelines for the evaluation, diagnosis and management of children and adults with celiac disease.
“Celiac disease (CD) is defined as a permanent immune-mediated response to gluten present in wheat, barley and rye. CD has a wide spectrum of clinical manifestations that resemble a multisystemic disorder rather than an isolated intestinal disease,” Alberto Rubio-Tapia, MD, director of the Celiac Disease Program at the Cleveland Clinic and assistant professor of medicine at the Mayo Clinic, and colleagues wrote in The American Journal of Gastroenterology. “Current treatment of CD requires strict adherence to a gluten-free diet and lifelong medical follow-up.”
In this update to the 2013 ACG guidelines, Rubio-Tapia and colleagues evaluated various clinical practice statements including indication for screening, diagnostic strategies, the role of biopsy-confirmed diagnosis, general approach to management and adherence, preventive care and more.
An expert panel created eight updated recommendations, which include the following highlights.
- Multiple biopsies of the duodenum, which include one or two from the bulb and four from the distal duodenum, are necessary for CD diagnosis.
- Among patients who experience lack of clinical response or relapse despite adherence to the gluten-free diet, upper endoscopy with intestinal biopsies may be helpful for monitoring.
- Although consumption of oats seems safe for most patients with CD, a subset of patients may be immunogenic.
- Vaccination against pneumococcal infection is safe and effective and is “widely recommended” for all adults aged 65 years and older and smokers aged 19 to 64 years, as well as adults with underlying conditions.
- Patients with symptoms or evidence suggestive of malabsorption, including chronic diarrhea with weight loss, steatorrhea, abdominal pain and bloating, should be tested for CD.
- Current guidelines recommend testing for CD in children aged younger than 2 years include evaluation of tissue transglutaminase (TTG) and deamidated gliadin peptide, although TTG and endomysium antibodies may be less accurate among this subset of patients.
“The updated guidelines suggest multiple areas of research needed at the end of each recommendation, which is a new change since the 2013 guideline and hopefully stimulates celiac researchers to work on these specific topics,” Rubio-Tapia told Healio. “The updated guideline is all about patient care and may inform non-expert gastroenterologists and other health providers, including dietitians and fellows, about quality care for celiac patients from diagnosis to management.”
Perspective
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Claire Jansson-Knodell, MD
Patient care is at the forefront of this latest version, as it focuses on screening guidance, accurate diagnosis and longitudinal management of patients in the clinic. Those who are symptomatic with chronic diarrhea, weight loss, bloating or abdominal pain or who are at high risk should be tested for celiac disease.
The guidelines advocate for a case-finding approach and against mass screening. The tissue transglutaminase immunoglobulin A is the screening test of choice for all ages — it is the preeminent test for screening. A positive serology result requires upper endoscopy with adequate duodenal biopsies (one to two bulb and four distal) to confirm the diagnosis. Patients should be monitored long-term after diagnosis with a goal of intestinal healing. Preventive care measures, like pneumococcal vaccination, are recommended.
The guidelines state that some new technologies and adjuvant treatments require more investigation. Insufficient evidence was found to support the use of gluten detection devices. Similarly, insufficient evidence was available for or against the use of probiotics. Numerous areas of interest were highlighted for further study and the next iteration of the guidelines is likely to be just as action-packed.
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